Drawing on relevant perspectives from both the private and public sectors, the Institute of Medicine (IOM) Forum on Public–Private Partnerships for Global Health and Safety (PPP Forum) held a workshop on November 18–19, 2014, to explore motivations, challenges, and lessons learned during four stages of partnerships: engagement, formation, operations, and knowledge management. Workshop objectives were to engage in forward-looking multisectoral dialogue on the evolving models of partnerships for improving global health and safety; to explore opportunities for identifying and applying lessons learned from experiences of success and failure; and to discuss how the evolving model of partnerships and lessons learned can impact the future state of global health and safety, help meet global developmental challenges, and sustain improved outcomes. This workshop in brief is a factual summary of what occurred at the workshop. It does not include findings, conclusions, or recommendations. Established in 2013, the PPP Forum illuminates opportunities that strengthen the role of partnerships in meeting the health and safety needs of individuals and communities around the globe, particularly those in low- and middle-income countries (LMICs). Exploring Lessons Learned from Public–Private Partnerships to Improve Global Health and Safety was the second public workshop of the forum. More information on the forum and its activities is available at www.iom.edu/publicprivatepartnerships.

Meeting Global Health and Safety Challenges

Current and future global health and safety challenges affect multiple sectors and are wide ranging. They include risks from emergence and spread of new microbes and microbial resistance, the rapidly increasing burden of non-communicable diseases and injury, health inequality across regions and communities, and the challenges in addressing them posed by insufficient institutional capacity and limited access to care. Recognizing the complexity and scale of global health and safety challenges, Laura Herman from FSG emphasized the amount of resources needed to address them and the limits of available resources and organizational capacity of governments, civil society, and philanthropy. She noted that as generators of income and wealth, the private corporate sector has resources and capacity to offer, along with these other global health and safety stakeholders. Through partnerships, resources across sectors have the potential to complement one another and create more effective and sustained change.

Keynote Address: The Role of Partnerships in Improving Global Health and Safety in LMICs - Francis Omaswa, ACHEST

The Evolving Models of Partnership

In recent decades, the shift of the percentage of funding for global health and safety that is being provided from public-sector entities in high-income countries to the private sector is significant. As noted by Wendy Taylor from the U.S. Agency for International Development, this shift creates a development environment that requires new thinking about the roles and influence of both the public and private sectors. Herman noted that in addition to the amount of investments, the way in which the corporate sector is investing is shifting and growing to include not only philanthropy and corporate social responsibility (CSR), but also strategic business investments through shared value. Beyond shifts in who the outside stakeholders are and how they are investing, Francis Omaswa from the African Center for Global Health and Social Transformation (ACHEST) illuminated the changes in how stakeholders within host communities perceive their role in investments that are being made. He cautioned that for aid and investments in LMICs to be successful and sustain impacts, host countries and communities need to be engaged in partnerships and have ownership of the activities and outcomes. Taken together, these shifts provide opportunities for alignment of interests among the private and public sectors and host communities, and the creation of partnerships that can meet global health and safety challenges.

Shared Value

Based on the work of FSG, Herman presented shared value as a management principle for corporate-sector engagement in global health and safety that differs from philanthropy and CSR. Shared value focuses on solving societal problems through core business activities while creating economic value. Herman defined shared value as corporate policies and practices that enhance competitiveness of the company while advancing social and economic conditions in the communities in which it sells and operates, including reconceiving markets and products, reconfiguring value chains, and enabling local cluster development. She added that shared value suggests that all profit is not necessarily equal: “Profit that involves shared value actually enables society to advance and [helps] companies to grow faster.” Although many corporations feel pressure from shareholders to tap into growing markets in LMICs, they are often unsure how to do so. Herman suggested that part of the reason shared value has been received favorably by the corporate sector is that it meets businesses where they are and meets their responsibilities in terms of shareholder value. But she cautioned that because corporations will make business decisions based on where they have a competitive advantage (and it will not be everywhere), corporate portfolios should not be just shared value. A robust portfolio also includes CSR and corporate philanthropy.

Collective Impact

Although shared value is a management principle for the corporate sector to use when addressing global health and safety needs, Herman presented the framework of collective impact as a mechanism for how to engage and leverage resources through partnerships. Referencing the complexity, unpredictability, and scale of global health challenges, Herman suggested that collective impact provides an opportunity for stakeholders to come together around a common set of goals, share their lessons learned, and identify not only how to work together, but also determine where each stakeholder can contribute the most effectively to meet the collective goals. Within a collective impact framework, stakeholders from government, nonprofit, philanthropic, and corporate sectors work together to solve a specific social problem through five conditions:

A common agenda: A common understanding of the problem, a shared vision for success, and a shared strategy for change.

Shared measurement: Agreement on the ways success will be measured and reported, with a short list of common indicators identified and used for learning and improvement.

Mutually reinforcing activities: A diverse set of stakeholders, typically across sectors, which coordinate a set of differentiated activities through a mutually reinforcing plan of action.

Continuous communication: All players engage in frequent and structured open communication to build trust, ensure mutual objectives, and create common motivation.

In reflecting on shared value and collective impact, IOM President Victor Dzau asked, “What about the people who are going to benefit? How do they become part of the public–private partnership; how do they engage in a conversation?”

As alluded to in Dzau’s questions, and presented in depth by Omaswa, for partnerships to have meaningful and sustainable impact, community engagement is needed. To develop trust, partnerships need to involve communities in design and implementation. Many workshop speakers repeated this lesson. As Jack Watters from Pfizer emphasized, the solution is about understanding what a community wants, not assuming what it needs. Martina Gliber from Fondation Mèrieux underscored that within partnerships, while there may be a coordinator who facilitates among all partners, the driving force is the beneficiaries who will sustain the project.

Developing community ownership and engagement that can sustain the impacts, Omaswa suggested, must come from working with communities, identifying their needs with their input, and listening to them. Omaswa explained the typical outcome of investments made without engaging host communities: “If you give me something because you think you have it and I don’t have it, but in fact I know inside me I don’t really need it, I don’t want it, but since you are giving it to me and I can use it, okay, you bring it. But when you go away, I throw it away as well.” Ownership, he explained, is the beneficial feeling that this is mine, this is what I want, and it is indigenous and comes from inside and cannot be given. To promote community ownership, Omaswa suggested growing capacity from within by supporting local institutions and governments to expand locally driven research, strengthen management and leadership, improve sharing of information, close the implementation gap, and improve monitoring and evaluation of performance. He recommended that partners or potential partners should advocate and promote good governance and accountable governments, and support local academic and technical professionals through professional associations, academies, universities, and think tanks. Omaswa also emphasized the importance of local context—political, social, and cultural—and stressed that developing capacity for community ownership takes time and patience. Types of partnerships are detailed further in Box 1.

Motivations to Partner

Understanding the motivations of different stakeholders to engage in partnerships provides insight into the value partnerships bring to furthering their organizational objectives and meeting their global health and safety interests. For example, from a corporate perspective, Allison Tummon Kamphuis from Procter and Gamble (P&G) suggested that the development of innovative new commercial products through corporate research and development alone may not be enough to reach markets and consumers of global public goods. Partnerships can serve as facilitators.

She gave the example of the P&G Children’s Safe Drinking Water Program. In the 3 years following the development of its water purification packet, the company was only able to distribute 3 million packets globally. To achieve better reach and distribution, the company started engaging in partnerships and now has distributed nearly 800 million in the past 10 years. Tummon Kamphuis explained that although it was originally marketed as a commercial product for consumer markets in LMICs, the product proved challenging to market with sufficient return on investment, given the need for education and behavior change within communities that had not previously been introduced to this type of product. In response to these challenges, P&G transformed the water packet distribution into a philanthropic effort and built strong partnerships with nonprofit organizations as distributors and educators of the product. Tummon Kamphuis noted that while the Safe Drinking Water Program is run as a philanthropic initiative, P&G still benefits from return on its investment in the program through employee recruitment and retention; opportunities to gather data and learn about potential consumer bases in LMICs from communities, local nongovernmental organizations (NGOs), and governments; demonstration of innovation; and opportunities to share experiences and best practices from their long-term engagement to other partnership activities. Brenda Colatrella from Merck agreed that the benefits to corporations from their involvement in global health and safety initiatives, whether CSR focused or integrated into core business activities, are not limited to financial gains and include benefits such as improvements in corporate reputation and employee engagement.

Speaking from a U.S. government perspective and specifically the President’s Emergency Plan for AIDS Relief (PEPFAR) program, Lauren Marks from the U.S. Department of State commented that the involvement of the private sector in responding to the HIV epidemic can increase both the sustainability and scalability of PEPFAR’s programming. She suggested that business interest in countries where PEPFAR is operating has the potential to endure beyond PEPFAR’s engagement and thus sustain impacts. To identify where there is alignment between PEPFAR and private-sector goals, and potential for partnerships, PEPFAR has performed a gap analysis to identify where the best opportunities are for the private sector to complement PEPFAR’s core goals and programming. The partnership agenda is one of the five key agendas for PEPFAR’s Blueprint for an AIDS-Free Generation. Katherine Bond from the U.S. Food and Drug Administration (FDA) provided an additional government perspective. She noted that to meet FDA’s mission within the context of the regulatory challenges posed by globalization of supply chains and increases in imports, regulatory cooperation and partnerships can scale up efforts to protect the public, enhance trade, and enhance food and medical product safety. Partnerships contribute to FDA’s overall objective to strengthen regulatory systems, as part of health systems strengthening.

Speaking from a foundation perspective, Lesley Graham from the Bill & Melinda Gates Foundation commented on the foundation’s reliance on partnerships to complement its own strengths. She noted that although the foundation brings significant resources to the issues it addresses, such as funding and its convening power, it has limited staff and relies on partners for implementation to meet its organizational objectives. To enable partnerships, the foundation has developed multiple financing mechanisms and tools. From an NGO perspective, David Oot from Save the Children provided several reasons why the organization engages in partnerships to further its mission: to generate and use evidence to leverage policy change; to leverage resources to support evidence generation, use, and expansion of program implementation; to achieve scale and greater impact; and to build local capacity.

Providing a perspective from an organization that is building capacity in LMICs, Carel IJsselmuiden from the Council on Health Research for Development (COHRED) emphasized that achieving and sustaining global health is crucially dependent on the capacity of LMICs to use science and innovation to solve their own priority health and development problems, both on their own and in partnership with high-income countries and their researchers, innovators, and institutions. COHRED is motivated to engage in partnerships for financing, technical support, and scaling and implementation to build capacity in LMICs and ensure that the development priorities of LMICs are represented within global health and partnership agendas.

Formation and Operations:Challenges and Lessons Learned

Collaborative efforts to address recognized global health and safety priorities often garner significance interest and support across a spectrum of stakeholders from the public and private sector; however, harnessing this interest into commitments and operationalizing into concrete action, with the development of an agreed upon governance structure and measureable targets for success, can be an obstacle. Throughout the workshop, speakers shared challenges and lessons learned from their experiences with partnership formation and operations.

Creating Organizational Readiness

Elaine Gibbons from PATH suggested that, to engage successfully in partnerships, organizations should take steps toward internal readiness, including (1) recruiting and retaining talent with multisector experience; (2) adapting the organization’s operating model to support new alliances; and (3) managing organizational behavior change to ensure effectiveness. Within the area of organizational behavior change, several other workshop speakers emphasized the need for mind-shift changes within organizations, and across sectors, to be able to effectively manage partnership engagement and operations. Drawing from the collective impact framework, Herman identified four critical organizational mindset shifts: (1) from technical problem solving to adaptive problem solving; (2) from short project cycles to commitments of 5 years or more; (3) from staff operating in risk-adverse cultures to entrepreneurial cultures; and (4) from competitors as enemies to competitors as potential collaborators. Joe Ruiz from the UPS Foundation provided a specific example of this fourth mindset shift with the Logistics Emergency Team, an initiative of the Global Logistics Cluster, in which multiple corporations within the same sector are collaborating to respond to disasters and logistical supply management. He noted that while it took several years to negotiate guidelines and build trust within the group, they now have an established track record from their coordinated response to a dozen disasters since 2007, and the collaborative efforts have strengthened UPS’s individual objectives.

Developing a Shared Vision and Strategy Among Partners

Gliber emphasized the value of engaging partners, particularly partners that represent target communities, before the formal partnership formation stage. This step ensures an alignment of interests among the partners, agreement on the objectives, and active engagement of all partners in the governance structure. Early within the partnership formation stage, Oot emphasized the importance of clarity of expectations and manageable interest of the partnership, and Bond underscored the need for clarity of goals and shared objectives among the partners. As the partnership is being formed, Gliber commented on the importance of defining roles for the all the partners, including responsibilities and expected results. Beyond defining roles for the partners, Marks suggested defining who all of the actors are, who among them are partners, and if there are roles within the partnership for actors who not necessarily partners, but are still important stakeholders.

A noted challenge in partnerships that focus on LMICs was establishing equity among the partners, as the available resources that each partner brings can vary significantly. However, Sir George Alleyne from the Pan-American Health Organization emphasized that this challenge should not be a barrier to creating effective partnerships, and general principles to promote equity can be established.

In developing a shared vision and strategy, Gibbons offered several important requirements: clarity on the unique assets each partner brings, development of a portfolio of opportunities within the partnership, and understanding of the implications of managing these assets and opportunities. Susan Rae Ross from SR International suggested that partnerships need shared goals and objectives as well as shared risks within the partnership, and the partnership needs a structure that includes joint operations decision making and interdependent resources and approaches. Throughout this formation stage, Bond noted the challenge, but importance, of creating a space to cultivate trust and confidence within a group of stakeholders to successfully implement and operationalize the lessons being learned.

Establishing Governance

An important element of partnership operations that was mentioned throughout the workshop was governance. Ross noted that the varying governance needs and complexity of structures and processes will be based on the scope, size, and number of partners within the partnership. In developing a partnership’s governance model, Ross suggested several questions to be addressed: Are different stakeholders’ views being held? How will goals be operationalized? How will disagreements be managed? How will decisions be made? B.T. Slingsby from the Global Health Innovative Technology Fund in Japan provided an example of a unique model of governance that was developed to structure conflict of interest assurance mechanisms among the partners. He noted that the development of the governance model was the result of sustained dialogue among partners throughout the partnership formation stage during which potential conflicts of interest were discussed openly.

Allowing for Course Corrections

In addition to establishing partners, developing shared goals and strategies, and establishing governance structures, Watters commented on the need to create mechanisms that allow partnerships to course correct during their operations. He provided an example of a partnership where the science on which it is operating has changed in the interim and thus needs to adjust. Within the context of course correcting, Colatrella noted that the issues and concerns of different partners are not always transparent, and there is a need for established trust and respect among partners so they can communicate effectively about what is working and what is not, then course correct as needed.

Sharing Credit for Success

Colatrella and Oot both commented on the importance of equally sharing credit for successes among partners. Ross emphasized the importance of discussing during the formation stage how recognition and credit about successes will be disseminated, as partners will have varying policies and procedures governing how they can publicly announce their involvement. Colatrella elaborated that many partners operate in highly regulated environments, and finding agreement on how to publicly disseminate information can be a challenge; however, sharing the credit and recognizing the contributions of all the partners is important for fostering shared ownership and responsibility.

Impact and Knowledge Management:Challenges and Lessons Learned

In addition to the partnership engagement, formation, and operations stages, speakers discussed several areas of challenges and lessons learned within later stages of partnerships, including: taking partnerships to scale; the sustainability, dissolution, or evolution of partnerships and their impacts; and measurement and evaluation.
Taking Partnerships to Scale
Wendy Taylor commented that in looking across partnerships, many of them are struggling to garner commitments to continue and scale beyond their initial phase. Sarah Gelfand from the International Partnership for Innovative Healthcare Delivery suggested that to take partnerships to scale, there is the potential to learn from small pilots and innovations that have shown success; proven and documented successes of small-scale efforts can be effective for informing and encouraging investments and support of larger-scale partnership efforts.

Within the context of large-scale partnerships that have achieved proven and documented large-scale impacts, Adrien Chaisemartin from GAVI, the Vaccine Alliance, underscored the opportunities for increasing impact at scale. While GAVI has had significant success globally through its partnership model, through documented evaluation of its successes and impacts, the partnership recognizes the untapped potential of stronger country-level partnerships to reach underserved regions and communities within countries. Although complex, it is an opportunity to assess how to better leverage resources in countries, including country offices of intergovernmental organizations, corporations with country offices, and local NGOs and civil society, and consider new models for coordination, funding, and the role of the Secretariat.

Sustainability

Several workshop speakers and participants discussed the challenges of sustainability and their strategies for addressing it. Chaisemartin mentioned GAVI’s innovative funding mechanisms for securing long-term funding. Elizabeth Cameron from the U.S. National Security Council and Marks emphasized their focus on building partnerships with strong private-sector stakeholders whose interests may be more long term than public-sector investments and priorities. Omaswa stressed the value of community ownership for sustaining impacts. Colatrella noted that the definition of a sustainable partnership can vary, and can include a successful dissolution of the partnership or an evolution into something else rather than sustaining the partnership itself. Considering the varying outcomes of what could be successful sustainability and how to achieve it, Bond asked if there may be a need to think about new models for partnerships that promote sustainability.

Measurement and Evaluation
Throughout the workshop, individual speakers and participants emphasized the need to evaluate and measure the successes and failures of partnerships and shared lessons on what to measure and how. Ross offered several key evaluation areas: how success is shared and communicated, evaluation of the partnership process, whether the problem been solved, whether enough value has been created to continue the partnership, and whether the partnership needs to be redesigned to continue to prove value. Colatrella emphasized the importance of developing these evaluation and measurement questions and mechanisms at the beginning of the partnership rather than waiting until the closure or renewal stage. Gibbons commented on the importance of evaluations that are designed to measure the effectiveness of partnerships for all stakeholders.

Opportunities Moving Forward

During the workshop, individual speakers identified several priority areas that would benefit from deeper exploration:

Distribution of partnerships:

Alleyne proposed that a better understanding of the distribution of partnerships, both thematic and geographic, would provide an opportunity to identify where partnerships are working and where there are potential gaps.

Perceptions of partnerships within the global environment:

Ambassador John Lange from the U.N. Foundation noted that the acceptability of certain principles around partnerships and their role in global health and scope of operations may vary among cultures, regions, and types of actors. A greater understanding of the perceptions of partnerships across contexts would be beneficial.

Growth in multiple stakeholder alliances:

Wendy Taylor commented on the growth of multiple stakeholder alliances. Although managing many different interests within the partnership presents challenges, there are opportunities for benefits from such partnership models, such as reduced transaction costs and developing more effective governance and funding models. A better understanding of the complexities and benefits would be an important emerging area to illuminate.

Learning from failures:

In addition to learning from successful partnerships, great opportunities exist to learn from failures. While there can be a reluctance to share failures, Colatrella proposed exploring ways to share that can benefit the larger stakeholder communities while maintaining anonymity of the individuals.

Addressing sustainability:

As Colatrella highlighted, what it means for a partnership to be sustainable can vary, including successful dissolution or evolution into something new. Given the varying outcomes that can define successful sustainability, Bond suggested reconsidering models for partnerships and how they promote sustainability.

Role of intergovernmental organizations:

Alleyne identified the role of intergovernmental organizations as part of the public sector and a stakeholder community within partnerships for global health and safety as an area that would benefit from further clarity.

Sustainable development goals (SDGs):

Jo Ivey Boufford from the New York Academy of Medicine identified the development of the SDGs and the role of partnerships in advancing the post-2015 development agenda as a timely area for further exploration.

Sharing of capabilities:

Watters commented on the opportunities for developing and better understanding the potential of partnerships that focus on sharing of capabilities, such as the regulatory capacity partnerships in which the Pan American Health Organization is involved.

Engagement of host country governments:

Lange commented that the complexity of global health and safety issues cuts across sectors, such as finance, the environment, and transportation. Identifying and sharing best practices for engaging multiple sectors within host countries would be beneficial.

This workshop was one of the first public activities of the IOM Forum on Public–Private Partnerships for Global Health and Safety. The presentations and discussions illuminated areas and opportunities for the forum to explore in its ongoing convening activities. More information on the forum is available at www.iom.edu/publicprivatepartnerships.

Disclaimer: This workshop in brief has been prepared by Rachel M. Taylor, rapporteur, as a factual summary of what occurred at the meeting. The statements made are those of the authors or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the National Academies.

Reviewers: To ensure that it meets institutional standards for quality and objectivity, this workshop in brief was reviewed by Katherine Bond, U.S. Food and Drug Administration, and Simon Bland, UNAIDS. Chelsea Frakes, Institute of Medicine, served as review coordinator.